Fears over the dilution of the generalist role should not hold back the need for some fresh thinking, says Dr Gun Soin
There is no doubt that a strong primary healthcare service is the basis of an effective healthcare system.
International evidence repeatedly shows that health systems with strong primary care provision produce better outcomes, higher levels of user satisfaction and lower costs. And central to the provision of a high-quality primary care is the general practitioner.
Despite this, general practice as we know it, faces significant challenges which threaten its very existence.
We as general practitioners, pride ourselves on being one of the last bastions of “generality” in an increasingly fragmented medical landscape, of silos of sub- and super-specialisation. We provide broad and holistic care to our patients and aim to do this from birth to death, providing continuity, accessibility and support.
We strive to improve preventative care and health promotion for our patients, while all the time the burden of disease increases and the interventions required to do this effectively multiply. We endeavour to improve patient access to our services to encourage engagement, with early morning, evening and weekend appointments despite finite time and resources.
We have increased the length of these appointments, to avoid “six-minute, sausage machine medicine” and give patients the time they need for their increasingly complex needs and increasingly complex management, on the background of an increasingly ageing population with an enlarging chronic disease burden.
We try to maintain our role as gatekeeper to the huge expense to both patient and the taxpayer of over-investigation and specialist care, minimising unnecessary referrals, while faced with increasing anxiety about medicolegal ramifications, time and funding pressures and increased patient expectations.
This is not sustainable.
A general practitioner is defined as a doctor who not only treats acute and chronic health conditions, but also who deals with preventive care and the promotion of health education to the community.
“The Declaration of Alma-Ata” at the International Conference on Primary Care in 1978 expanded on this, with a detailed and comprehensive statement about the role of primary care in the community and this remains relevant today.
As well as guidance about reflecting on and addressing health issues arising from socio-economic factors and involvement with related industries including food, education and housing, key points include promoting participation in the planning, organisation, operation and control of primary healthcare, making fullest use of local, national and other resources, and importantly that “primary care should be sustained by integrated, functional and mutually supportive referral systems”.
And this is the key. While individually GPs will no longer be able to be all things to all people, we should aim to create models of primary healthcare which enable us, as a group, to come close.
We need to be innovative and look at different ways of doing things – not just picking and choosing bits that seem like they work from other countries’ healthcare systems.
The approach needs to be broad and bold, while not abandoning those things that work well.
The local needs of Australia are unique and specific, particularly in view of the huge variations in healthcare provision and need between metropolitan and rural areas.
Balancing the important role of providing continuity of care for the management of our patients’ long standing health needs with the provision of high quality, accessible acute care in the community may require us to think about reconfiguring these services into separate entities with “urgent-care” GP-led clinics running in parallel to existing services, perhaps.
Increasing complexity of the management of the conditions we encounter means that we often find ourselves at the limits of our comfort zone.
However, most of us have particular areas of expertise which our colleagues can draw on – for example women’s health, dermatology or paediatrics. While we often informally draw on each other’s skills with chats in the coffee room or getting our patients to see our colleagues within our practice, surely this can be done better and on a bigger scale.
We must not shy away from developing these skills further in fear of diluting our role as “the generalist”.
An expansion of services provided by GPs with special interests, in conjunction with improvements in training and mentoring these GPs, could avoid the need to burden our specialist colleagues with patients and conditions that could be managed effectively, safely, conveniently, and at a lower cost, in a community setting.
Encouraging GPs to have extra skills will empower us by creating further opportunities for professional development. Allergy services, endoscopy, sexual health services, diabetes clinics, weight-loss management programs, minor surgery, musculoskeletal services, pain services – these are all examples of services which can be effectively run by GPs within a community setting in collaboration with allied healthcare professionals and supported by our specialist colleagues.
Ensuring that systems are in place to ensure high quality in the provision of these services, and to promote more collaborative working within local GP networks, will be vital.
So, as the landscape continues to change and the pressures on the system continue to rise, many of us begin to lament the passing of “traditional” general practice with post-apocalyptic fears about what lies ahead. However, with this change we have not just an opportunity, but a duty to ensure that general practice remains the central pillar of our healthcare system and has the ability to maintain its relevance in the uncertain future.
Dr Gun Soin is GP Editor for The Medical Republic
